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76 South Riverside Drive Batavia, OH 45103 Phone: 513-732-7363

www.clermontcountyveterans.com Hours of operation are Monday-Friday 7:30 am to 4:30 PM

vso_ --======' DATE ______ --'

TIME. ______ __;

The determining factors to qualify for Emergency Financial Assistance are:

1. IT AROSE UNEXPECTEDLY 2. Created an immediate need for financial assistance 3. The situation at hand or in question was not a result of the applicants own misconduct

Standard Information for ALL Emergency Financial Claims

DD-214 (all if more than one) State ID or Driver's License Proof of 90 Day residence in Clermont County Current Lease or Mortgage Statement Current utilities bills Medical, dental and vision bills Verification of all other expenses (auto payment, credit card statement, home repair, etc.)

Income and Expense Documents for last 60 Days

Payroll Check Stubs or Wage Reports Unemployment compensation documentation VA pension or compensation documentation Social Security Income/Disability documentation Retirement payments (PERS/FERS, union, etc.) Verification of all other income (rental properties, child support, worker's comp., etc.) If self-employed, monthly profiUloss or quarterly tax statements Checking, savings, credit union or direct pay debit activity

Dependent Verification

Birth and death certificate (if applicable) Marriage certificate/divorce decrees/legal separation documentation Custody/adoption documentation

Other pertinent documentation

If unable to work, current letter from a medical physician Police and fire reports(if applicable) All estimates or receipts for unexpected expenses If requesting auto repairs proof of current insurance

A Note on Fraud: Submission of any false information during the application process may lead to criminal prosecution. as well as rejection of the application for aid. Every applicant seeking financial assistance from the Veterans Service Commission will be required to sign a

statement Indicating that all Information submitted on the application is truthful and accurate. Clients who submit fraudulent case information may be prohibited for all future Veterans Service Commission assistance.

Clermont County Veterans' Service Commission

Emergency Financial Assistance

Name: Date:

Status: D Veteran D Spouse D Widow D Dependent

Have you received assistance in this office previously? D Y es Cl'J o

The purpose of our financial assistance program is to provide emergency financial assistance to veterans in need. It is the responsibility of the veteran/applicant to show proof that their current financial situation is an EMERGENCY and relief is justified. We consider all household income, living expenses, available assets, medical expenses and the special needs of each veteran/applicant when determining eligibility.

The veteran upon whose service the application for financial assistance is made must have been discharged "Under Honorable Conditions" and must have served at least 90 days active duty for purposes other than training (DD-214 required). The veteran/applicant must be a resident of Clermont County for 90 days and submit proof of that residency - (i.e. utility bill, lease, mortgage statement, etc.).

We may provide assistance for the following; Rent/Mortgage, Utilities (excluding Cable), Food, Medical (limited).

Please complete the attached questionnaire and application for financial assistance and provide the following documentation:

Copy of your /veteran's DD Form 214, copy of valid Ohio Driver's License or State ID. We will also need copies of your utility bills, mortgage statement, and lease for proof of residency.

(We will not provide financial assistance to any veteran/ applicant without a copy of the DD Form 214 or equivalent.)

1. Please explain why you are in need of f'mancial assistance in space provided below:

2. How did you bear about us: D Billboards D TV D Radio D Family D Friend D VA Hospital/Clinic

D Other ___________ _

FINANCIAL ASSISTANCE APPLICATION/STATISTICAL DATA SHEET

This application must be completed by answering all questions. (Note: Disclosure of Social Security account numbers is voluntary, but failure to provide such information may affect your application for financial

assistance.) Social Security numbers are used as secondary identifiers to determine an applica nt's eligibility for assistance.

***PLEASE FILL OUT ENTIRE FORM***

1 Veteran's Name: Last First M.I. SSN Last Four ONLY XXX-XX-- -Occupation:

2 DATE OF BIRTH: I DATE OF DEATII: I MARITAL STATUS: DATE OF MARRIAGE: I DA TE OF DIVORCE/S EPA RA TJON:

3 SPOUSE (MAIDEN NAME IF APPLICABLE) SPOUSE SSN: SPOUSE DATE OF BIRTH:

4 VETERANS ADDRESS (filiQUIREO) CITY (REQUIRED) STATE (REQ!JIRED) ZIP (REQUIRt:O) HOW LONG?

5 DATE ESTABLISHED RESIDENCY IN THIS COUNTY: (PROOF REQUIRED) I TELEPHONE NUMBER (REQUIRlill)

6 PREVIOUS ADDRESS: CITY: STATE: ZIP: HOW LONG?

7 NAME OF CURRENT LANDLORD/MORTGAGE CO. I TELEPHONE I FAX

IF APPLICANT IS NOT THE VETERAN. PLEASE COMPLETE THE FOLLOWING: 8 NAME: I RELATION TO VETERAN:

I DATE OF BIRTH: SSN Last Four ONLY

XXX-XX---

9 ADDRESS: CIT Y : STATE: Z IP: TELEPHONE (AREA CODE)

MILITARY SERVICE (MUST HAVE PROOF OF SERVICE)

10 DATE FROM: TO: TYPE OF DISCHARGE: BRANCH OF SERVICE: VERIFIED (OFFICE USE ONLY)

Y ES - NO - DD214 - VA

11 DATE FROM: TO: TYPE OF DISCHARGE: BRANCH OF SERVICE: VERIFIED(OFFICE USE ONLY)

YES - NO - DD214 • VA

LIST ALL RESIDENTS OF HOUSEHOLD 12 NAMES: HOW SSN"S: DATE IN CUSTODY PROVIDE

RELATED: OF OF WHO: SUPPORT? BIRTHS: YES- NO

13

14

15

16

17

18 OOES ANYONE ELSE LIVE IN YOUR HOUSEHOLD AND ARE THEY VETERANS? (IF YES, PLEASE EXPLAlNJ

19 HAVE YOU OR ANYONE IN YOUR IIOUSEIIOLD EVER APPLIED FOR ASSISTANCE FROM ANY OTHER AGENCY IN THE LAST ~O DAYS? (IF YES. PLEASE EXPLAIN)

20 AGENCY : ASSISTANCE

21 AGENCY: A SSISTANCE:

EMPLOYMENT VETERAN SPOUSE OTHER

Employer Name:

Employer Address:

Employer Phone:

Dates of Employment:

Rate of Pay: $ $ $

ARE YOU SEEKING EMPLOYMENT? WHERE: ARE YOU REGISTERED WIT H JOB AND FAMILY SERVICES?

IF NOT SEEKTNG EMPLOYMENT, EXPLAIN WI-IY:

ASSETS TYPE $VALUE TYPE DESCRIPTION $VALUE LOAN OWED

CHECKING HOME

SAVINGS OTHER PROPERTY

CD VEHICLE

OTHER VEHICLE

OTHER OTHER

INCOME AND EXPENSES PRESENT MONTHLY NET INCOME MONTHLY BILLS PAID ASSISTANCE REQUESTED

(Last 30 Davs) (REQUIRED) (Last 30 Davs) (REQUIRED) lREOUIRED)

Wages - Veteran $ Food $ TYPE AMOUNT

Wages - Spouse $ Shelter $

Wages - Children $ Water $

Pension or Compensation $ Electric $

Retirement Benefits $ Propane/Oil $ Social Securitv - Veteran $ Telenhone $

Social Securitv - Soouse $ Cable $

SSI $ Auto Pavments $ Welfare $ Insurances $

Food Stamos $ Credit Accounts $

Child Suooort $ Recurrinl! RX/Medical $

Unemployment Benefits $ Transportation $

Workers Comp $ Dav Care $

All other income $ Child Suooort $

$ • ~,,,1~., I n,:,nc $

$ Rant tn r.,.,n $

$ $ $ $

$ $

$ $

Total $ Total $ Total $

I UNDERSTAND THAT FALSE STATEMENTS MADE ON THIS APPLICATION MAY LEAD TO PROSECUTION. I HAVE COMPLETED AND/OR REVIEWED ALL INFORMATION PERTAINING TO MY APPLICATION FOR FINANCIAL ASSISTANCE AND I CERTIFY THAT IT IS CORRECT TO THE BEST OF MY KNOWLEDGE. UNDERSTAND THAT BY SIGNING THIS APPLICATION I GIVE PERMISSION TO ANY GOVERNMENT ORGANIZATION TO REVIEW THE COMPLETE FINANCIAL FILE AND GIVES CCVSC PERM ISSION TO OBTAIN INCOME AND EMPLOYMENT DATA FROM OTHER GOVERNMENT AGENCIES.

--Date Signed Applicant's Signature

CLERMONT COUNTY AUDITOR'S OFFICE 101 E MAIN STREET

BATAVIA, OHIO 45103 http://www.clermontauditor.org

AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT OF CLERMONT COUNTY WARRANTS

• To sign up for ACH/EFT, please provide the information requested in SECTIONS 1 and 2 • Any account changes must be reported to the Clermont County Auditor's Office thirty (30) days prior to actual

change. • Payee must keep the Clermont County Auditor's Office informed of any address and bank changes in order to

receive important information about benefits and to remain qualified for payments.

A. TYPE OF TRANSACTION

B.

ADD

NAME OF COMPANY OR INDVIDUAL

ADDRESS

c. O• DDDDDDD

SECTION 1

CHANGE DELETE

COUNTY {AREA CODE) TELEPHONE

CITY STATE ZIP CODE

D.

Print Form

FEDERAL TAX ID OR SOCIAL SECURITY EMAIL ADDRESS FOR REMITTANCE NOTIFICATION

SECTION 2

A. -----------------FINANCIAL INSTITUTION NAME COUNTY (AREA CODE) TELEPHONE

ADDRESS CITY STATE ZIP CODE

B. TYPE OF ACCOUNT SAVINGS CHECKING

••••••••• C. TRANSIT ROUTING/ASA NUMBER

••••••••••••••• ACCOUNT NUMBER AT ABOVE INSTITUTION

• We hereby authorize the Clermont County Auditor's Office to initiate credit entries to our account in the financial institution identified above and also debit entries, if necessary, for any credit entries that are determined to be in error. We additionally authorize the financial institution to credit or debit the same to our account.

• This authority to remain in effect until revoked by us in writing to the Clermont County Auditor's Office.

Applicant Signature Printed Name Date

Do Not Write Below This Line-For Clermont County Auditor's Use Only

Date Received Vendor ID Number Date Entered Initials